AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.

The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.

However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.

In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.

The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.

While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.

"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.

"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."

The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.

"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.

For a more detailed account of the ruling, refer to the original report by AFCA.

Published:Wednesday, 4th Sep 2024
Author: Paige Estritori

Please Note: We do not endorse any specific products or companies. Some content is sourced from third parties, including press releases, and may not be independently verified for accuracy or completeness.

Share this news item:

Insurance News

Clear

HESTA Announces 12% Reduction in Insurance Fees for Members

25 May 2026: Paige Estritori

HESTA, a prominent superannuation fund in Australia, has unveiled a significant reduction in insurance fees, averaging 12% across all cover types. This initiative, effective from 1 July 2026, aims to provide more accessible and affordable insurance options for its members, including those in the trades sector. - read more

Suncorp's AU$2.4 Billion Reinsurance Deal Strengthens Financial Outlook

25 May 2026: Paige Estritori

Suncorp, a leading Australian general insurer, has secured a substantial reinsurance agreement valued at up to AU$2.4 billion over five years. This strategic move has positively impacted the company's fiscal 2026 growth outlook, resulting in a notable 10% increase in share value. - read more

Zurich's AU$415 Million Acquisition of ClearView Signals Market Consolidation

25 May 2026: Paige Estritori

Zurich Financial Services has announced its agreement to acquire ClearView Wealth, a listed life insurer, for approximately AU$415 million. This acquisition is part of a broader trend of consolidation within the Australian insurance market, following similar moves by other major players in the industry. - read more

IAG's Strategic Response to Softening Commercial Insurance Market

17 May 2026: Paige Estritori

Insurance Australia Group (IAG) is proactively addressing the challenges posed by the current soft commercial insurance market through its Intermediated Insurance Australia (IIA) division. CEO Jarrod Hill has expressed confidence in the division's ability to navigate these conditions, citing a well-balanced business portfolio and strategic operational adjustments. - read more

Tasmania's Collaborative Strategy to Enhance Insurance Affordability

17 May 2026: Paige Estritori

The Tasmanian Government has announced a significant shift in its strategy to address insurance affordability and availability within the state. Premier Jeremy Rockliff revealed plans to collaborate with insurers, brokers, and reinsurers to develop solutions that effectively tackle these issues. - read more

Click for more Insurance News